Howard Dean on a Public Sector Option: Why Single-Payer Advocates and Progressives Must Unite

During a recent appearance on MSNBC’s Hardball, former Gov. Howard Dean (D-VT) said that a public insurance option is essential to any health reform effort (Thanks to Igor Volsky for pointing this out on The Wonk Room, and Hat-tip to Dr. SteveB on Daily Kos.)

Here is what Dean said: “If Barack Obama’s bill gets changed to exclude the public entities, it is not health insurance reform…it rises and falls on whether the public is allowed to choose Medicare if they’re under 65 or not. If they are allowed to choose Medicare as an option, this bill will be real health care reform. If they’re not, we will be back fighting about it for another 20 years before somebody tries again.”

As I have suggested in the past if private insurers are forced to compete on a level playing field with a public sector option (which some call Medicare-for-All ) this means that they will be tightly regulated in terms of what they must cover. It also means that they will not be able to “cherry-pick” by charging some customers more because they are older or because they are sick.

Without the public sector option, I’m just not confident that Congress will have the spine to regulate the for-profit insurance industry. If Medicare-for-all is competing with private insurers, Congress will be forced protect the public plan from unfair competition—or face the wrath of tax payers fed up with corporate welfare.

Is the President Leaving This Decision to Congress?

I'm concerned that a public-sector insurer was not included in the principles for health reform listed in the President’s budget. As Brian Beutler points out on his blog “These principles call for universality [the mandate that everyone must have insurance], but not for a public option. That seems pretty backwards to me. The mandate should in theory be popular with insurance companies (in fact, it should be non-negotiable for them) and it ought to be used as a bargaining chip so that they can't just put all their efforts into fighting other truly progressive measures like the public option. Handing over the mandate gift at the outset and then hoping they agree to a public option down the line, or after the legislation's been introduced makes things much, much harder.”

I agree. Of course the for-profit insurance industry wants the individual mandate. It is hungry for more customers. But it should have to compete for those customers. I believe President Obama supports some version of Medicare-for-all, but he seems to be leaving this decision to Congress—at least for now. And I am afraid that some in Congress are in such a hurry to pass legislation that they might cave to the lobbyists on this one. I know that conservative Congressmen will join the insurance industry’s lobbyists, fighting tooth and nail, to make sure that all of the formerly uninsured become the captive customers of the for-profit industry.

What Public Sector Insurers (including the VA) Could Bring to Reform

A public sector insurer could join with Medicare in beginning to reimburse doctors and hospitals for value, not volume. Rather than rewarding healthcare providers for doing more, Medicare is making plans to start paying for care based on how much patients benefit. Because public sector insurers are so much larger than any single private insurer, their combined clout would give them the muscle they need when negotiating a new payment structure with the “brand name” hospitals discussed here.

When I refer to “the public sector insurers,” I’m thinking of Medicare, Medicare-for-all and perhaps a VA-for-all plan. As Dr. Atul Gawande pointed out in a recent New Yorker article, the VA has the ability to offer more effective, safer care than fee-for-service Medicare while spending 30 percent less. So why not open up both Medicare and the VA as public sector alternatives? I have written about this here and here 

Of course, the VA would need more funding—Vets shouldn’t stand in longer lines because the uninsured have joined their system. But according to the AP the Obama administration already is planning to boost the VA healthcare budget by 10 percent, so that non-disabled veterans whose income exceeds $30,000 can receive care. Opening the door to non-Vets would require further funding, but taxpayers would get a bigger bang for their dollars than they would with fee-for-service Medicare.

That said, Medicare has begun experimenting with moving beyond “fee for service,” and the funding for “comparative effectiveness research” that President Obama has secured will help further the effort to pay more for more effective care.

Why don’t for-profit insurers do their own comparative effectiveness research? One reason is that they know that patients frequently switch from one company to another; thus private sector insurers don’t have an incentive to think in terms of what would be best for the patient over the long term. Medicare, by contrast, knows that it is stuck with the patient for life. (And some have suggested that under healthcare reform, patients who choose the public sector plan should be required to stay with it for at least five years, giving the plan the same incentive to take the long view when it comes to preventive care, or managing chronic diseases.)

Secondly, when for-profit insurers make a treatment decision, most people assume that they are simply trying to say money. And too often, that has been the case. In the 1990s, when HMOs were trying to “manage care” they were supposed to compete on quality. But too often, they focused on cost, not quality, rewarding providers and drug-makers who provided less expensive services and products ---whether or not they were effective.

Finally, healthcare is an area where we need government to promote the public good. For-profit insurers must answer to shareholders; inevitably this creates a conflict of interest, and undermines public trust that insurers will put patients ahead of profits. But if a public sector insurer begins setting standards, it is likely that many not-for-profit insurers would be eager to join Medicare-for-all in competing on quality. Ultimately, in the battle for market share, for-profits also would have to begin focusing on finding the most effective care for their customers. If they didn’t they soon would fall by the wayside.

Won’t a Public Sector Insurer Driven Providers’ Fees Into the Basement?

I don’t think so. If the fees are too low, physicians and hospitals will refuse to take patients with public-sector insurance. And we know that Americans value having a choice of hospitals and providers. The public sector plan will need to strike a delicate balance, or it will wind up with only the poorest—and sickest—patients.

Admittedly, I do worry about ending up with a two-tier private/public system with the best care reserved for those who can pay higher premiums. But as health care economist Uwe Reinhardt points out , “if public plans institute rock bottom rates that aren’t accepted by health care providers” and Americans “have a choice of private plans alongside the public plan” most would choose a private insurers. “The public sector plan, would then either wither away,, says Reinhardt, “or it would have to raise fees until it is competitive in the market for enrollees.” I agree, but I also suspect that, in order to avoid two-tier system, one for the poor, one for the rich, government regulation will be needed. Again, ublic and private sector plans should be competing on quality, not price.

One way to solve the problem would be for the government to give every American a voucher of equal value that would pay for equally rich coverage. (The vouchers might be funded by a combination of employer contributions and taxes.) Every family could then choose whatever insurance plan seemed to offer the best care, without worrying about price. Insurers would compete to try to put together a network of hospitals and doctors that combined the best outcomes with shorter hospital stays, fewer readmissions, fewer missed diagnosis and fewer errors. (This is a variation on the “voucher” system proposed by Dr. Ezekiel Emanuel in his book Health Care, Guaranteed., It would, I think, be an excellent way to ensure equitable care. (Emanuel is now chief health care adviser to White House budget director Peter Orszag. )

Would A Public-Sector Plan Drive Private Insurers Out of Business?

Conservatives argue that a public sector insurer would have an unfair advantage because its administrative costs are lower. As the Commonwealth Fund points out in its recent,proposal for a “High-Performance Health Care System,” Medicare spends 5 percent of the money it receives on paperwork and salaries; by contrast, for-profit insurers shell out an average of 15 percent of premiums on paperwork, salaries for executives, advertising, lobbying and profits for shareholders.

This 10 percent difference is significant, but in theory, for-profit insurers are nimbler and more innovative than large government bureaucracies. At least this is what most conservatives argue. Now is the time to find out. We cannot afford to pay more for care in order to keep inefficient private insurers in business. Healthcare is too important. It must be affordable for all Americans. (For a detailed argument see the Urban Institute’s brief on how a public-sector insurer can help control costs while contributing to constructive competition here.

Calling All Single-Payer Advocates

Progressives will not be able to win this battle with conservatives, private insurers and their lobbyists unless we unite. This means that we need single-payer advocates to join with progressives in insisting that, at the very least, health care reform must include a public-sector plan as part of the mix. I recognize that, from a single-payer perspective, this is not ideal. But it will be far worse if we find ourselves the captives of a health care system run by and for private insurers simply because progressives remained too splintered –and too stubborn--to fight together on this single issue.

Comments

[Don Levit]

Deron:
You asked an excellent question.
How has the federal government functioned as an insurer, in regards to Social Security and Medicare?
In the GAO report entitled Budget Issues, Budgeting for Federal Insurance Programs, issued in Sept. 1997, it discusses the importance of maintaining reserves, so that federal programs are fully funded. "The government's cost would be funded from the perspective of the program, but not of the government as a whole since under current practice reserves are held in Treasury securities (borrowed by the Trasury to finance other government spending)."

And, how does the FASAB (the accounting advisor for the federal government) look at social insurance? Does the federal government have any fiduciary obligation to its citizens?
In its paper Accounting for Social Insurance, Revised, issued in 2006, it states - "A nonexchange transaction arises when one party receives value without directly giving or promising value in return. There is a one-way flow of resources or promises. In regards to social insurance benefits the federal government gives value to beneficiaries without receiving value in return. The fact that benefits paid are not based on the amount of taxes paid confirms the nonexchange nature of social insurance."
This provides a new light on the definition of an entitlement program!
Don Levit

[Maggie Mahar]

Deron S.--

That is a good question.

As I keep saying, how would you feel if, in 8 years, Jed Bush were elected president, with Bush buddies from around the nation coming into Congress on his coattails.

We have had bad government before.

If we have single payer, what would a bad government do to U.S. healthcare? And we would have no alternatives.

The presumption that a government run healthcare system will always put patients ahead of corporate profits just isn't based on reality.

For much of the past 29 years we have had governement that often put corporate profits ahead of Americans. . . .

Things might very well be different under Obama (as they have been under past good governments), but American voters have a history of also electing
corrupt governments.

Obama will not be president forever.

I definitely want a government-run health care system as an option--and I believe it will be successful. But, in bad times, I want an atlernative

[Lisa Lindell]

Geez, miss a day around here! It's going to take me a month to get caught up. I really don't understand all the single-payer hootenanny. We live in a capitalist country, even if the single payers get what they want we still won't have a single payer system...like I've said before we have public and private schools, it would go the same way in health care.

[Deron S.]

One question that MUST be asked in any single-payer debate is: How do you feel about the overall performance of the U.S. Government over the last 15-20 years? Do you feel that it has been effective and efficient?

[Maggie Mahar]

Dr. Steve B.--

Thanks much for the very kind apology.

As I think you know, from my past replies to you both on the blog and off-blog, I like and respect you.

But I just don't want this blog to attract trolls.

And if non-trolls like you begin to use it as a billboard --then trolls will follow.

I hope you will continue to post comments.

[DrSteveB]

My last several posts were replies to direct queries by other posters. But my apologies to Ms. Mahar if I over-did-it. It is her blog.

[JMG]

If we are to proceed with side-by-side plans, and, as both Mahar and Reinhart both suggest, let the public plan set "prices" and let the private plan negotiate prices, then the connsuer check-and--balance on the reasonableness of the public rates requires an "open door" policy to let providers and patient switch between them. This is NOT liukely to be the case -- i.e., providers will almost certainly be required/mandated to participate in the public plan. Further, there's no real evidence in its 45 years that Medicare has EVER set a price "correctly." Witness overpayments for IOLs, underpayment for PCPs, and lethargic prices for physician-administered drugs. Put simply, there's no evidence in the US market of administered prices doing anything good to our healthcare system. Further, the issue is less price, and more volume -- so imagining a federal plan controlling volume is a bit of a stretch, Finally, what;'s the unit price-setting mechanism in a public plan? Perhaps we can collectively discuss how best a public plan SHOULD set prices in a way that balances supply and demand. I'm all for all-payer rate setting in the abstract, but as someone who has worked in and around Maryland all his life, I'm not sure it's practical at any level below inpatient, and if we are to move to bundles and episodes, all-payer rate-setting will need to define more than just the base price of a DRG admission.

[Maggie Mahar]

Pat S.-- Thanks for
providng some reality-based facts,

Single-payer advocates:
As I thought I had made clear, I will not allow HealthBeat to become merely a platform for advertising links to
propganda for one cause or another.

We delete posts if someone is selling something.

If someone is making an argument, with evidence and numbers that are true, particuarly if they are responding point by point to other arguments that I have linked to (the Urban Institute explaning administrative costs, for instance) that is fine.

But a series of links to articles, videos etc that I dont' have time to check out it not fine.

I don't want any misinformation spread by this blog.

That's why advocates for x, y or z are not welcome to post their ads here.

If these comments continue, they will be removed. If the writer tries ot re-post he or he will be barred from commenting on HealthBeat

I dont' like to do that-- Dr. Steve, Jack, Harriette and other single-payer advocates have made good contributions in the past.

But this is becoming a rant ( And, Jack, I don't like some of the language.

[Pat S]

"Politics is the art of the possible." -- Bismark

"Politics is not the art of the possible. It consists in choosing between the disastrous and the unpalatable." -- John Kenneth Galbraith.

In the best of all possible worlds, we would create a single payer system or a true social insurance system.

However, despite the fact that some polls show that both the majority of Americans (depending how the poll is worded) and the majority of physicians favor a single payer system, only a small percentage of the politicians who will make the program happen -- fewer than 20% of House members and at this point no senators -- endorse this plan.

In this setting, I think that Maggie is right. We need to concentrate not on a futile effort to pass single payer now, but rather on passing a program that contains features needed to create a reasonable program and that may offer the possibility of evolution toward single payer or social insurance.

There are features of a potential health plan that progressives, both single payer advocates and otherwise, need to focus on:

1.) True universal care, offering both coverage for everyone and coverage plans with premiums, deductibles, and co-pays that do not act as a barrier for people to get or to use the insurance.

2.) Community rating for premiums and a "no exclusion" feature, selling insurance for the same rate for all comers in the community and ending exclusion of people with "pre-existing" conditions and health risks.

3.) Creation of a federal option insurer open to all people and employers to act as an honest broker and to provide a low cost option. This program should be made part of Medicare, Medicare should be adjusted to conform to the aforementioned elimination of high premiums, co-pays, and deductibles, and the state SCHIP and Medicaid programs should be ended and replaced with participation in this federal option.

4.) Creation of a Health Effectiveness Board to collect and create studies to measure effectiveness and quality of health care, publicize the results, and make the results binding on federal programs, including Medicare, Medicaid, SCHIP, and any new federal insurance programs.

If we accomplish this, we will have laid the groundwork for successful reform of the health system and for cost savings that can make health care affordable, not just for individuals, but for the economy and the nation as a whole. And we will have laid a groundwork for single payer or for social insurance, if the system proves it can work.

[Lynn M]

You mention "Medicare for All" in your post. I recently read an article on http://www.FierceHealthCare.com that covers the California Nurses Association/National Nurses Organizing Committee's support for health reform being centered around "Medicare For All." They've recently published an analysis that shows how it would benefit all Americans. Research conducted by the Institute for Health and Socio-Economic Policy says using such a program would create 2.6 million jobs and generate $317 billion in new business and public revenues, and supply $100 billion to the U.S. economy. According to the article, thirty percent of the jobs would be created in the health and social services sector, but jobs would also be created in other areas like retail, food services, and administrative areas.

[Harriette Seiler]

Reading all these comments including those from my beloved friends in the single payer movement, I am even more confirmed in my opinion that blog commentors should have a word/character limit.

Why are single payer advocates being asked to join self-described progressives who are trying to maintain and protect (indeed bail out) the private multi-payer system? In this economy we can't afford to pay 15 to 30- cents of every health care dollar to the insurers who DO NOT PROVIDE care? (Maggie, I return to the Himmelstein-Woolhandler estimate of private sector administrative costs including waste and inefficiences).

The political fesibility argument just doesn't fly anymore. Ask the CBO to "score" the savings if we implement HR 676.

A letter to the editor in Louisville's newspaper this past week came from two highly regarded physicians being aqueezed by insurers. It reminded me of the old story "First they rejected the poor, then they rejected the chronically ill, then they came for those with pre-existing conditions, then they came for the union members and the retirees, then they came for middle class families, then they came for the charity hospitals . . . and then they came for the doctors . . .." I'm probably mixing metaphors but you get the point. How much inhumanity and inequity are Americans willing to stand?

Believe me, no Canadian cancer patient has to pass a means test before getting chemo, no parent with a child in need of a transplant has to hold a bake sale to pay for treatment.

I agree with Dr. Rob Stone of Bloomington, IN. He suggests we enact Medicare Plan E-- Expanded and improved Medicare for Everyone!

Oops I'm exceeding my self-imposed word limit.

[DrSteveB]

Reply to Jack & Deron:
Below are direct links to short versions of the case for single payer:

Two Great videos depending on whether you have 3 minutes or 2 minutes (the context is California state single payer, but same applies nationally):

OneCare video 22 minute version:
http://www.youtube.com/watch?v=gAWZrfYXs-c&feature=channel_page

One Care video 3 minute version:
http://www.youtube.com/watch?v=GyWiVLdR47c&feature=channel_page

1-2 page Single Payer talking points:

Key Features of Single (American Journal of Public Health January 2003, Vol 93, No.1):
http://www.pnhp.org/facts/key_features_of_singlepayer.php

Issues for single payer legislation:
http://www.pnhp.org/PDF_files/Issues_for_sp_legislation.PDF (.pdf)

Upgrading To National Health Insurance (Medicare 2.0)-The Case For Eliminating Private Health Insurance, by Leonard Rodberg & Don McCanne
CommonDreams.org, July 13, 2008:
http://www.pnhp.org/news/2007/july/_health_insurance_fo.php

Talking Points: Why the mandate plans won't work, and why single-payer "Medicare for All" is what we need
http://www.pnhp.org/news/2008/december/talking_points_why_.php (web version
http://pnhp.org/change/TalkingPoints.pdf (.pdf version)

Top Ten Reasons Why We Don’t Need Private Health Insurance &
Top Ten Reasons Why We Should Not Require that People Buy Private Insurance (the so-called “individual mandate”
http://pnhpnymetro.org/20-reasons-to-end-private-insurance.doc (.doc)

PowerPoint slide shows free to use from PNHP NY Metro Chapter: http://pnhpnymetro.org/slide-shows.htm

Why Business should support single payer http://pnhpnymetro.org/business-case-for-NHI.pdf (.pdf; a little bit older)

[Jack Lohman]

As well, here's a web page I wrote in an effort to communicate the whole issue at once.

http://moneyedpoliticians.net/medicare-for-all/

DrSteve, have you just one document that tells it all. I'd sure like to see it.

And, I just don't believe we must accept a compromise because "the insurance industry wants to."

Whaattt??? Who gives a diddly-damn what those leeches want? This country ... our politicians ... must quit tinkering around the edges trying to satisfy ANYBODY other than the needs of this nation! We don't need incrementalism, we need them to do it right the first time around. And then let's get on to solving the rest of our economy problems.

But it starts with healthcare, and if we don't fix that correctly, the rest will not be fixed effectively.

Here's a must-see video by Air America:

http://greatnorthernhealth.blogspot.com/2009/03/remove-leeches-pass-hr-676.html

[DrSteveB]

replying to Deron:

The best starting place is here:
http://www.pnhp.org/facts/single_payer_resources.php

For some of my stuff, try here:

http://www.dailykos.com/story/2009/1/13/8135/23887/977/683458

&

http://www.dailykos.com/story/2009/2/25/85211/4019/280/701460

&

http://www.dailykos.com/story/2009/2/20/82651/6270/47/699667

& here:

http://www.dailykos.com/story/2008/11/25/7564/6432/1022/666148

and more at:

http://www.dailykos.com/search?offset=0&old_count=30&string=author%3DDrSteveB+and+tag%3Dhealth&type=diary&sortby=time&search=Search&count=50&wayback=3153600&wayfront=0

[Don McCanne]

Maggie,

You say that you don't want to start up the single payer debate again, but I hope that you can forgive us for reacting to what seemed to be your invitation to join in support of "a public sector plan as part of the mix." That is interpreted by us as a multi-payer system, which automatically removes single payer from consideration.

Most of us who advocate for single payer also do support beneficial increments, such as the inclusion of SCHIP expansion in the stimulus package. But these increments are considered to be urgent, temporary measures to help now, as we continue to move forward to achieve the ultimate goal of... yes, single payer.

The reason that we do not actively support the public insurance option in a market of private plans is that it would require us to abandon our support for the single payer model, at least until we have a couple more decades of proving that the public/private model won't work either (and we do have a large amount of data indicating that it would fall far short of reform goals).

Single payer supporters do understand that if a market of private plans were an absolute given, then the addition of a public option would certainly be beneficial. But this is where we split. We cannot accept the fact that a market of private plans is already a done deal, so we continue to advocate in a loud, clear, unwavering voice for the single payer model.

We are not driven by political probabilities; rather we are driven by a passion for those policies that would be most effective in providing affordable, high quality care for everyone.

[Deron S.]

Dr. SteveB - I just joined the discussion and I haven't followed any of your comments elsewhere, but exactly when are you going to show support for your argument that single-payer is the answer for this country?

Also, do you have any thoughts on how much it will cost to make the transition and how long it will take?

[DrSteveB]

We agree 100% that there is much to be learned and implemented from the best of technocratic do-goodnik HMOs, the VA, etc. More power to the Kizners, Berwicks, Geisinger, Kaiser & Halvorsons, etc. But I think that you are conflating the issue of the source and stream of funding (single payer) with organization of delivery of care. Single-payer promotes competition among the deliverers of care, be they individual physicians, HMOs and MCOs in the original sense of the word, and hospitals.

And of course single payer has its version of the independent health board planning board. So those smart and good folks will either be running winners on the service deliver side, or running the system from the independent board or from improved and expanded CMS.

Your examples of gutting Medicaid in some states is exactly the example of what happens when you have two tier system, and the poor get screwed. Same for the NYC hospital competition for “white” (aka: wealthy with high quality private insurance) patients (similar to the public schools). Two-tiers is bad and creates bad competition for all the wrong things including expensive unnecessary care (per the Dartmouth folks). Most of your counter examples seem to me to be from the bad incentives in our current fragmented and mostly for-profit system.

A person of the same age with the same health problem gets different care based on their health insurance plan and income; and also other access issues (how close to a place of care, education and knowledge of the system; mobility/transportation; and also on their race and other appearance issues also, but that is antoher story), as well as the perverse provider driven excesses of care if there is oversupply of specialists.

We agree I think on all this. Just don’t see where your alternative differs. Either it is also done under single payer with competition based on cost and quality by the provider side of the equation . Or you are creating two tier system.

We agree and don’t want to recreate that nationally. Again if you can come up with a system with useful competition that does not degenerate into two tiers, let me know. I think single payer does envision the benefit of service delivery side competition. We also agree about excess salaries and incomes by some executives and doctors at the high-end. Again, rationalizing reimbursement, paying more for thinking and less for proceduring might help is likely under single payer. Paying more for setting up practice in poor and less desirable areas (inner city and rural) and paying less not more for those who set up shop on Park Avenue, Bel Air or wealthy suburbs. But all done easier under single payer.

[Jack Lohman]

Maggie, I hesitate to inject myself into a disagreement between you and DrSteve, but I sure disagree that it is misinformation to say that "the majority of Americans want single-payer."

True, when you mention that employer coverage will be replaced by Medicare, you’ll get people thinking. But if you are going to disclose that, then you must also disclose everything else that goes along with single payer, like lower overall costs and 100% coverage, and the fact that they may not have their employer coverage much longer, and even if they do they are paying hefty prices at the cash register for it, and the job market has been trashed because of it, and it has had serious effects on our economy, then I think reason will set in. Given ALL of the information I think "the majority of Americans will STILL want single-payer."

[Maggie Mahar]

Dr. Steve.

I understand the economics of healthcare very, very well. And I undestand the politics.

I have spent years studying both.

So let's just agree to disagree.

I intended to reach out to single-payer who might see a hybrid planas better than all-private national insurnace.

(Politcally, it is far more likely that we will wind up with an all-private plan than with single-payer.)

But I did not intend to start the whole single-payer is the only way debate all over again.

There are plenty of places to have that debate. This blog is not one of them. The people who read this HealthBeat are sophisticated enough to understand the arguments on both sides.

They have heard the arguments before--many times, and have made up their own minds.

They don't need to hear a rant.

And I don't want HealthBeat used to spread misinformation--i.e. "the majority of Americans want single-payer."

As you know, this is not true when someone explains that if we have single payer, everyone has to be in the pool, which means that the 85% of Americans who have employer-based insurance subsidized by their employers have to give it up for the govt plan.

[DrSteveB]

more...

Who is being radical shrill ideologue?

Multiple independent analyses by “gold standard” organizations that are not single payer advocates – GAO and CBO in the 1990s, and Lewin Group multiple times in the 2000s (and Paul Krugman and Joe Stiglitz) – have all concluded that Single payer is the best for controlling total costs and providing care that is universal and comprehensive. Polls suggest that 60% of Americans and physicians would support it. While there is an argument to be made that our proposal is tough to pass in our corrupted form of democracy, our proposal (and we) are not being radical or shrill or even progressive. It is just the best. Cassandra was not being radical or shrill. She was right; they were wrong. It is those who insist against all objective independent evidence that there something wrong with single payer and they have found the magic alternative (e.g., Zeke Emanuel, Dartmouth Atlas folks), or ignoring the other half of what single payer is about (e.g., Maggie Mahar- we are not only about the for profit insurance company waste; we tackle the other issues you raise and better than if the system is left fragmented with multiple conflicting interests, no global budgeting, no strategic planning), or just waffling and ignoring and refusing to get past yes, but-ism (Uwe Reinhardt) that are the shrill ideologues of false moderation.

I have no problem with folks who argue it cannot pass congress in 2009-10. The politics of it are definitely arguable. But stop the endless dodging around the policy and economics.
I do have a problem who blame us for being shrill, radical and counter-productive to the cause. We were not the ones who blocked Clinton-care in 1993-94. Gingrich, Dole, Bill Kristol, the resistance by the insurance companies and the rest of corporate America (some of whom overtly double-crossed the Clintons’ who thought they had them onboard as part of the pre-compromise; sound familiar?), etc. did that. Push comes to shove, we dutifully fall into line and vote the least bad bill (and Bill) out there. But from 1994 onward, when nobody else gave a damn, it was single payer advocates PNHP, HealthCare-Now, CNA, etc who were still doing the grassroots work. It is very nice for HCAN and whatever the SEIU grand coalition of the week is called, to take their foundation and corporate sponsor money on the condition that single payer is off the table. It is very nice for Kaiser and Commonwealth to tell us off the record they agree single payer is the best, but their board and funders won’t let them say so. It may be that if you advocate for single payer you wont get invited to good receptions in D.C. That may be the way things work. But it is not a policy or economic argument.

As to leaving not-for-profit systems in place:

The worry is about creating a two-tier system where the rich and upper middle class can opt out. There is nothing wrong with the NYC public school system, that having all the rich and upper middle class kids who are in private school having to go to public school would tend to fix. If you can come up with a system that creates useful competition on the payer side, but without sucking away resources from the public system and creating two tiers, I’d be interested in listening. I just don’t want all the plastic surgeons and dermatologists, and half the cardiologists in one system, depleting the public system by their absence.

[Jack Lohman]

This just boggles my mind. HR676 would save every corporation in the US $6000 per employee per year, and provide health coverage to 100% of Americans. Perhaps not alone, but certainly in tandem with other stimulus measures, it would go a long way toward saving the US economy. Medicare most certainly is the only system that will save the medical profession from the for-profit CEO vulchers.

But the insurance industry would rather continue collecting its profits, and the politicians would rather continue collecting their campaign contributions, and both have essentially given the finger to the rest of the nation as it goes down the tubes.

Could it lead to anarchy? I think it could. At 71 I don't have to worry about it much longer, but I worry for my kids and grandkids. What is this country made of?

[Maggie Mahar]

Hootsbuddy, Jim Jaffe, Pat S. Don--

See my responses to your comments, in my long comment posted Feb 28, 12:53 which begins "Dr. Steve B."
(Sorry, I forgot to put your names in the headline.)

[Maggie Mahar]

Dr Steve B=

Dr. Steve B-- Responding to your most recent comment first-- You write:

"There is every reason to believe that single payer would do a far better job of being able to address those issue than the fragmented, multi-payer system with different players having different incentives"

What reason is there to believe that single-payer will do a far better job of containing costs?

Medicare is a very large single-payer. It has the clout to negotiate prices on drugs, say "No" to unncessary treatments, trim waste, and cap doctors salaries.

But it hasn't done that.
Over 30 years (if you look at the charts I run) sometimes private insuers have done a better job of holding down spending, sometimes Medicare has done a better job.

As for refusing to cover ineffective DANGEROUS treatments-- Medicare covered bone marrow transplants for breast cancer patients throughout the 1990s; Medicare coverd Vioxx until it was pulled off the market.

Who refused to cover Vioxx? Kaiser. Who refused to cover those tortoruous hugely lucrative and totally useless breast marrow transplants? Some wise private-sector insurers.

For the last 18 years, at least, Medicare has been run by the lobbyists for the many groups that profit from our healthcare system.

Other countries are much better at containing costs because they do not view health-care as a for-profit industry, like any other, that should be left unregulated.

The problem here is not simply the for-profit insuers (a small piece of the puzzle) it's the for-profit drug-makers and device-makers (16 percent of our national healhcare bill) the physicians working fee for service and hauling home $300,000 to several million a year; the hospitals--for-profit and non-profit-- that use "surprluses" to pay exectuives a million or two million, and on cosmetics that will draw in well-heeled, well-insured patients. (A NYC hospital executive told me: In New York, competition among hospitals is all about competing for white patients."

That is what we are paying for. And we cannot afford it.

The only "single-payer" in the U.S. that has done a good job of containing costs and protecting patients? the VA.

One man, named Kizner transformed the VA in the 1990s. No one paid too much attentoin because these days, Vets are considered people who live on the fringes of our society. Most journalists don't know any Vets. So if someone denied them Vioxx--who cares?

If course it turned out that the vets were lucky-- the VA makes its decisions based on medical evidence,and so Vets on Vioxx didn't die of heart attacks and strokes the way Medicare patients did.

As do non-profit private insurers like Geisinger, Kaiser, etc.

Medicare does not.

See what I say below in my comment to Jim Jaffe about waste in Medicare.

And in the U.S. conservative governments have gutted Medicaid and SCHIP--leaving both to the tender mercies of states like Florida and Texas.

So, no Dr. Steve, we cannot trust the government to always represent the best intersts of the people.
And talk to doctors in the U.K. about what Thathcher did to the NHS. I have. IT still hasn't recovered.

Hootsbuddy--
I worry that a great many Americans (40 percent to 60 percent) would not be able to afford private insurance.
That is why I think there must be a cap on how much private insurers can charge--and very clear rules for what they must cover. No high-deductibles and no Swiss chesse plans with holes.
I also know many of teh people who would be in the bottom tier, and that is why a two-tier system is Not Fine with me.
Yes, the VA is like Kaiser and part of Geisinger--it insurers And it provides health care. This eliminates much of the conflict between payer and provider and is something we should keep in mind as a model.
No the VA is not commected to military healthcare. That is run (and often not well) by the U.S. army.

jim jaffe--
You are aboslutely right. Medicare is now paying out more than it takes in.
And it is extravagantly wasteful. CBO says that if we provided current Medicare to people 55-65, they would have to pay premiums of around $12,000--Per Person, Not Per Family.

Most people in that group couldn't afford that.

So we are going to have to make Medicare much less wasteful, much less extravagant.

That is what the funding Obama has secured for comparative effectiveness reserach is all about. Medicare will probably begin by upping co-pays and lowering fees for ineffective treatments that often are much more expensive than older,or less aggressive therapies.

My guess is that co-pays for angioplasties for patients who are stable will climb. Co-pays for mammograms for average-risk women under 40 and over 60 will climb. As Orszag has pointed out, there are many, mnay areas where we already have comparative effectivenss research and know that we are paying for inefective treatment.

Medicare also is likely to clamp down on those regions where the Dartmouth reserach shows that doctors regularly over-treat, costing Medicare 50 percent more (Metropolitan NY including suburbs in N.J. and CT, Boston all the way down to cost to Baltimore, much of Florida, sections of Texas, Louisiana (lots of hospital beds there has led to overtretatment) sections of Southern California)

Medicare is trying to figure out how to penalize over-treatment in those areas without penalizing doctors who are practicing conservative evidence-based medicine.

They'll probably start with the hospitials. Note that they are already saying that they won't pay for hostpial readmissions when the readmissions were caused by "sub par treatment."

Medicare will have to get
much more specific, and this will be controversial.
Did the patient really contract the infection while in the hospital, or
did he bring it in with him?

But this will give hospital CEOs a reason to pay much more attention to infections, errors (experimenting more with checklists) making sure that when a patient is being discharged,someone sits down and talks to the paitent (or family) about what he needs to do when he gets home--and communicates with his doctor.

Unfortuantely, many hospital CEOs are businessmen (not physicians) who will invest in something only if they know there are going to be financial consequences if they don't.

Keep in mind that one otu of three Medicare dollars is wasted on ineffective, unncessary, often unproven and over-priced treatments, drugs and devices. That's 33 percent.
We only have to trim about 6 percent from Medicare spending to put a lid on health care inflation. Many people think we can cut more than 6 percent without in any way undermining the quality of care.

Pat S.--
Thanks for the compliment.

On the VA --a couple of thoughts.

First VA docs in Vermont (near Dartmouth) tell me that patients regularly come down from Northern Maine (where there is no VA) even though they could get Medicare up there.
They make a six hour bus trip because the prefer the VA.
So some Americans are willing to travel for better care.
And I do think that oen of the things Americans need to learn is that the best care is not always going to be close to home. We are going to be naming certain hospitals "Centers of Excellence" for certain treatments. If you go to a center of excellence, your co-pays and deducgtibles will be much less.
Americans will learn to travel--just as people in some larger developed countries do.
As you suggest, we cannot afford to duplicate infrastructure --it's too expensive. And if people are forced to think about it, they will realize that the "tradeoff" of convenience over safety just isn't worth it.
I'd rather talk to my
husband on the phone and be in a hospital that's less likely to kill me.
Finally, no one would have to sign up for the VA-for-all. They could pick Medicare-for-all or private insurers. At the outset, probably relatively few would opt for the VA-- in the past it has had a poor reputation, and because our all-volunteer army tends to draw Americans from the bottom half of the income ladder, many Americans think of the VA
as healhtcare for poor people . .
Over a period of years, however, word-of-mouth might well lead more people to the VA, and over those years the VA could figure out how to grow.
But I don't see us building a lot of new VA hospitals. Some satellite
clinics, maybe.
Again, it's one of those things we need to experiment with, trying it in stages.
At the outset, the VA might be open to people 55-65--it's set up to care for people in that age group. Currently, it's not set up to care for young children.

Don -- Medicare is large enough to serve as monosphy-containing costs. (It's as large as entire healthcare systems in some developed countries that contain costs.)

But Medicare doesn't do it.
See my comment to Jim Jaffe.

[DrSteveB]

RE: Controlling costs:
Single payer, via monospony, global budgeting, and ability to do actually do strategic planning does/would address all the concerns regarding cost increases due to the other parts of medical inflation... overuse of non-useful technology/drugs, appropriate use of new wonder techologies, as well as the other talking points from Brownwell/Emmanuel, Dartmouth, Obama, etc. such as preventive health care, chronic disease management and Health IT. There is every reason to believe that single payer would do a far better job of being able to address those issue than the fragmented, multi-payer system with different players having different incentives (private for profit, private non-profit, government) that some seem to wish to leave in place. So I consider it to be a red herring (aka false) that somehow single payer does not also address those issues. We address the wasted overhead and profit of the fragmented private system health insuramnce AND ALSO those other issues too. Indeed, we do it better.

As to the concern about what happens if conservative republicans take control again? Well, when they have taken over they were NOT able to destroy Social Security or Medicare, because established well run univesal entitlement programs are popular. They are able to hurt those programs somewhat, especially with crap like Medicare Advantage" & Medicare part D. But that is democracy for you. Look to England, where Thatcher was not able to destroy NHS (mostly slow or pause fixes that needed to be done in redistribution of resources frozen from 1940s takeover; limit increase in legit expenditures and %GDP; but not destroy). Same with conservative government in Canada, Germany, France, etc. Not able to really attack popular competent universal program.

By comparison, I would suggest that having the private for-profits, and even the so-called not-for-profit (and IRS definition that may have little to do with the incentives and beliefs of management policy) is like having the most nasty obnoxious evil Republicans running our health care system all the time (we call it care; they call it medical-loss ratio; murder by spreadsheet).

[John Ballard]

==►“if public plans institute rock bottom rates that aren’t accepted by health care providers” and Americans “have a choice of private plans alongside the public plan” most would choose a private insurers.◄==

I saw Dr. Reinhardt's videos and have deep respect for his opinions, but he's been too long in the ivory tower. When he says "most would choose a private plan" he simply has no idea how many people make up the great unwashed.

I am at the retirement end of a long career in food service, having worked all my life with those disrespectfully called "the working poor" ...hard-working, responsible ordinary folks, many of whom have clean credit, mortgage-free homes and little to show for a lifetime of responsible living but a meager Social Security income plus Medicare.

Although I paid the max into Social Security and have a small pension, I am about to join that group. My mother and father (he was an auto mechanic) BOTH were Medicare and Medicaid clients. My wife and I have one rental property listed as a Section Eight property and we see that end of the population close up. In fact, my mother was a Section Eight client in a church-sponsored apartment facility approved for government assistance. One of our grandchildren was an S-CHIP beneficiary over a year when his parents started a small business with income and a staff level too low to afford group insurance.

A two-tier system looks fine to me.

And the VA, incidentally is distinct. That is as government "health care" as opposed to government "insurance," an important distinction made by an earlier commenter.

I don't know how Tricare works, but I was drafted in 1965 and served in the Army Medical Service Corps. I know at that time military dependents were eligible for medical care where ever facilities were available. That care, if it is still used, is ancillary to the VA, I would think.